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New Patient Enrollment

New Patient Enrollment

Once you submit this intake form, your Farmacann Cannabis Concierge will contact you as soon as possible to consult on your first order.

If you need help or have any questions please don’t hesitate to call us at 707.931.2333

Please note:
Your information will not be shared with anyone without your permission; we consider you to be a Farmacann Member, not just a Customer. Additionally, Farmacann has taken extra precautions to utilize HIPAA Compliant systems to insure your Membership Information is secure.

    Patient's Name*

    Patient's DOB*:

    Are you a patient or a caregiver?

    Delivery Address*


    Zip Code*

    Care Facility Name, if delivery is to a facility:


    Healthcare Providers may complete the electronic cannabis recommendation and use orders below:

    Cannabis eRecommendation 

    Farmacann Use Instructions

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